Pharmacy teams can support people with respiratory conditions so they can stay as well as possible, particularly during the winter months, as Steve Titmarsh explains…

Inadequate control of lung diseases such as asthma and chronic obstructive pulmonary disease contribute to poor outcomes for patients and an increased burden on health services as a result of more GP visits and hospital admissions.

Poor inhaler technique is known to be associated with poor outcomes for people with chronic obstructive pulmonary disease (COPD) and asthma. The Pharmacy Quality Scheme notes that ‘incorrect use of inhalers is very common and subsequently leads to poor control for both patients with asthma and COPD. For patients with COPD, incorrect inhaler technique increases the risk of severe flare-ups and hospitalisation.’¹

In the worst-case scenarios incorrect use of asthma medication or non-adherence can lead to death from an asthma attack – that applies to mild-to-moderate asthma as well as severe disease.²

‘Health inequalities are a long-standing problem, with people in the most deprived communities across the UK being twice as likely to develop a lung condition and seven times more likely to die from a lung condition and the cost-of-living crisis continues to deepen those inequalities,’ according to Asthma + Lung UK.³

Taskforce for Lung Health, a collaboration of over 40 different charities, organisations and patients working to improve lung health, said that ‘community pharmacies “hold the key” to levelling up lung health inequalities.⁴ Asthma + Lung UK advise patients that they ‘can ask your pharmacist about any concerns with your asthma, repeat prescriptions, stop smoking advice, and advice on losing weight’.⁵

As well as advice on medicines, their side-effects and inhaler technique community pharmacists can also assess how well a person’s asthma is controlled by using a questionnaire such as the Asthma Control Test,⁶ which asks people with asthma how they have been over the past four weeks, with questions such as:  

• Has asthma affected how much you get done at work, school or home?
• How often have you had shortness of breath?
• How often have you had asthma symptoms? (coughing, wheezing, chest tightness)
• How often have you used your reliever inhaler?

Darush Attar-Zadeh, a community pharmacist and an executive committee member of the Primary Care Respiratory Society, writing in a blog post in 2021, said that community pharmacists have the skills to advise and support people with lung disease to make best use of their medicines and understand what they are for.⁷

He likes to use the asthma RISKS acronym:

R – RATE: From a patient medication record the prescribing rate of inhaled corticosteroid (ICS) and short-acting beta₂ agonist (SABA) can be identified. For example, people receiving less than 75% of the ICS over a 12-month period and more than 2 SABA need some education and support. BTS/SIGN 2019 asthma guidelines advise that: ‘Anyone prescribed more than one short-acting bronchodilator inhaler device a month should be identified and have their asthma assessed urgently’; ICS should be considered for anyone using a SABA three times a week or more.^8,9,10

NICE guidelines published in 2021 advise that using a SABA for symptomatic relief three or more days a week constitutes a pragmatic threshold for uncontrolled asthma.¹¹

I – ICS: ICS potency should be reviewed and a step-down considered for people appropriately controlled.

S – Smoking cessation (ICS is less effective in people who smoke).

K – Knowledge: According to an Asthma UK survey around 50% of people with asthma do not have an asthma plan. Patients need to know what medicines they are taking and why they are taking them, as well as how to take them. Patient’s concerns and beliefs about their medicines are important to understand. All these factors have an impact on whether patients adhere to their medication – something that is crucial in the optimal management of long-term condition such as lung disease.¹²

S – Spacer and inhaler technique optimisation. For people using a pressurised metered dose inhaler a spacer can improve lung deposition and can help improve everyday symptoms with regular preventer use.

Studies have shown the value of community pharmacist involvement in the management of people with chronic lung disease. For example, in Portugal in 2019 researchers found that when pharmacists showed patients with a self-reported diagnosis of asthma or COPD how to use their inhalers correctly their technique improved and they had significantly fewer appointments with their doctors compared with patients in the control group.¹³

An earlier review of 10 studies from around the world looking at the impact of community pharmacists in the management of COPD from 2005 to 2015 concluded that ‘community pharmacists can have a positive impact in the management of COPD especially on inhaler technique education and medication adherence’.¹⁴

Conditions such as pulmonary fibrosis, one of a group of over 200 interstitial lung diseases, where a build-up of scar tissue in the lungs makes breathing increasingly difficult, tend to be diagnosed and managed under the direction of specialists in secondary care.¹⁵

However, community pharmacists still have a role in referring anyone they think may have such conditions to their GP for further investigation – those with symptoms of pulmonary fibrosis such as breathlessness, a persistent cough, feeling tired all the time and clubbing of fingers and toes.¹⁶

Breathlessness and persistent cough are also symptoms of a number of chronic lung diseases, including, for example, bronchiectasis in which coughing also brings up phlegm.¹⁷

Pharmacists can also offer people with chronic lung disease a range of advice and support to help improve symptoms and avoid exacerbations of their condition. General advice to help people to stop smoking, encouraging them to have a flu vaccination, as well as eating well and exercising regularly can be beneficial for people with any chronic lung disease.

The Asthma + Lung UK website has a range of information and resources to help support patients and health care professionals to improve the management of chronic lung disease.¹⁸ A handbook on chronic respiratory diseases for pharmacists is available from the International Pharmaceutical Federation.¹⁹

References

1. NHS England. Pharmacy Quality Scheme – guidance 2023/24 (www.england.nhs.uk/long-read/pharmacy-quality-scheme-guidance-2023-24; accessed January 2024).
2. Royal College of Physicians. National Review of Asthma Deaths (www.rcplondon.ac.uk/projects/national-review-asthma-deaths; accessed January 2024).
3. Asthma + Lung UK. People living in poverty are twice as likely to end up in hospital fighting for breath (www.asthmaandlung.org.uk/media/press-releases/people-living-poverty-are-twice-likely-end-hospital-fighting-breath; accessed January 2024).
4. Taskforce for Lung Health. Community pharmacies ‘hold the key’ to levelling up lung health inequalities (www.taskforceforlunghealth.org.uk/taskforce/press-release/community-pharmacies-hold-the-key; accessed January 2024).
5. Asthma + Lung UK. How do pharmacies work? (www.asthmaandlung.org.uk/conditions/asthma/asthma-care-nhs/pharmacist; accessed January 2024).
6. Asthma Control Test (www.asthmacontroltest.com/en-gb/welcome; accessed January 2024).
7. Attar-Zadeh D. Blog series – Asthma outcomes: Community pharmacy perspective (www.ed.ac.uk/usher/aukcar/news/insights/blog-series-asthma-outcomes-community-pharmacy; accessed January 2024).
8. Primary Care Respiratory Society. Asthma slide rule (www.pcrs-uk.org/resource/online-asthma-slide-rule; accessed January 2024).
9. Scottish Intercollegiate Guidelines Network (SIGN), British Thoracic Society. British guideline on the management of asthma. Edinburgh: SIGN, 2019.
10. Global Initiative for Asthma. Pocket Guide for Asthma Management and Prevention (https://ginasthma.org/wp-content/uploads/2023/07/GINA-2023-Pocket-Guide-WMS.pdf; accessed January 2024)
11. National Institute for Health and Care Excellence (NICE). Asthma: diagnosis, monitoring and chronic asthma management. NICE guideline [NG80] (www.nice.org.uk/guidance/ng80; accessed January 2024).
12. Murphy A. Everyone’s talking about – Reflections on the role and value of pharmacists in integrated respiratory care (www.togetherinrespiratory.co.uk/everyones-talking-about/reflections-on-the-role-and-value-of-pharmacists-in-integrated-respiratory-care; accessed January 2024).
13. Rodrigues AT, Romano S, Romão M, et al. Effectiveness of a pharmacist-led intervention on inhalation technique for asthma and COPD patients: The INSPIRA pilot cluster-randomized controlled trial. Respir Med 2021;185:106507.
14. Hesso I, Gebara SN, Kayyali R. Impact of community pharmacists in COPD management: Inhalation technique and medication adherence. Respir Med 2016;118:22–30.
15. Asthma + Lung UK. What is pulmonary fibrosis (www.asthmaandlung.org.uk/conditions/pulmonary-fibrosis/what-pulmonary-fibrosis; accessed January 2024).
16. Naqvi M. The role of pharmacists (www.actionpf.org/news/the-role-of-pharmacists; accessed January 2024).
17. NHSinform. Bronchiectasis (www.nhsinform.scot/illnesses-and-conditions/lungs-and-airways/bronchiectasis/#symptoms-of-bronchiectasis; accessed January 2024).
18. Asthma + Lung UK (www.asthmaandlung.org.uk; accessed January 2023).
19. International Pharmaceutical Federation (FIP). Chronic respiratory diseases: A handbook for pharmacists (www.fip.org/file/5230; accessed January 2024).